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rri�t VSt: -- /6 --------------- -------- APPLICATION FOR"SANITATION PERMIT Permit No. .......... ------- ----------------------- --- --------------------- (Complete in Duplicate) ----- This Permit Expires I Year From Date Issued Date Issued . f.. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------�t1_.. L r h -------------------------------------- Owner's Name--- - -------•----------------------------•-••------•----------------------------- - ---------------------- ------- Phone------------•-----------•----------- Address-•--------2-111_4_0 Contractor's Name------ -------- ---- �------------------------ Phone--------------.-.-.--_----------- Installation will serve: Residence A artme�e [- ' Commercial ❑ Trader Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -:.57-Number of baths 5 - Lot size ----2ro /..moo.................. Water Supply: Public system 9T- Community system ❑ Private ❑ Depth to Water Table .-(fa ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay p Adobe[.� aardpan ❑ Previous Application Made: (If yes,dote----------.---------) No New Construction: Yes ❑ No FMA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ank:) Distance from nearest well.................Distance from foundation_-_-_-.- Material---------------.--------------------------------- r No. of compartments-------------------------Size-.-------------•---------------Liquid depth-------- - --------------Capacity..-------------------- - Disposal Field: Disiance from nearest well.---�..-------Distance from foundation.�d_---__.-_....Distance to nearest lot Iine0:777_._..-. ( - Number of lines----I-----------------------------Length of each line__00------------------_._ Width of trench----2.4--'`____•------ ----- r Type of filter material__Jf Mk-------Depth of filter material___Ir--"______..Total length-.-___ o.'.-._-__-...__- "V Seepage Pit: Distance to nearest well---�------------Distance-from foundation..LA._--_--__- Distance to nearest lot line---S .... � Size: Diameter...-. 5R__ Number of pits._ Lining material '�3- Depth-----,.�:a----�------------ Cesspool: Distance from nearest well-----------------Distance from foundation..----------_.-.--.Lining material_._.-__-----------.._--.--..._..---- ❑ Size: Diameter-------- -----------------------------Depth------------ ---------------------------------------Liquid Capacity---------------------------gals, f Privy: Distance from nearest well---------------------------------.---------------Distance from nearest buildin ❑ Distance to nearest lot fine------- -------- ----- Remodeling and/or repairing (describe)------- ----- -------------------------------•-----------------------------••--- ---------------•--------------- F --------------------------------- ---------- ------------------------------------ -------------------------------- --- ------------------------------------------------ ---------------------------------------------------------------- -----------------------•-#----------------------------- --------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Sfinedces, State laws and rules and regulations of the San Joaquin Local Health District. I (Signed) /-------- j (Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------- (Title) `, ---=`------ � - (Plot plan, showing size'of lot, location of system in relation to wells, buildings, etc., can be placed'on reverse side). v. F011 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - =------------- DATE -1 � ---------- REVIEWED BY- ---------------- ----------------- DATE ------------------ BUILDING PERMIT ISSUED -- -------------- - ---- ---------- DATE ------------------ Alterations and/or recommendations•.-----...__ //�� -__ _____ ,�------- ��-------------------- ------------ --•----------------------------- ------------------------- - -7,—....e..�. _ . . -.__. ---------------- ---- --------------------------------- ---------------------- ------- ------------------------------------------ -- ------ 3 ----------------- ------- -------------- /�� FINAL INSPECTION BY:. - �C � - Date--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California . �.a.cQ.